切换至 "中华医学电子期刊资源库"

中华结直肠疾病电子杂志 ›› 2015, Vol. 04 ›› Issue (06) : 607 -612. doi: 10.3877/cma.j.issn.2095-3224.2015.06.07

所属专题: 文献

青年专家论坛

腹腔镜主导下个体化肛提肌切除的APE术
冯波1, 卢矫阳1, 郑民华1,()   
  1. 1. 200025 上海交通大学医学院附属瑞金医院普外科 上海市微创外科临床医学中心
  • 收稿日期:2015-10-15 出版日期:2015-12-25
  • 通信作者: 郑民华
  • 基金资助:
    2011上海市科委重点项目(11411950700); 国家高技术研究发展计划(863项目)(2012AA021103); 2012上海市卫生局重点项目(20130423); 2013上海交通大学医工交叉面上项目(YG2013MS26); 2013上海市卫生系统先进适宜技术推广项目(2013SY010)

Laparoscopic-cotrolled abdominaoperineal excision with individualized levator muscle transection

Bo Feng1, Jiaoyang Lu1, Minhua Zheng1,()   

  1. 1. Depatment of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai 200025, China
  • Received:2015-10-15 Published:2015-12-25
  • Corresponding author: Minhua Zheng
  • About author:
    Corresponding author: Zheng Minhua, Email:
引用本文:

冯波, 卢矫阳, 郑民华. 腹腔镜主导下个体化肛提肌切除的APE术[J/OL]. 中华结直肠疾病电子杂志, 2015, 04(06): 607-612.

Bo Feng, Jiaoyang Lu, Minhua Zheng. Laparoscopic-cotrolled abdominaoperineal excision with individualized levator muscle transection[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2015, 04(06): 607-612.

对于低位直肠癌的手术治疗,传统腹会阴部联合切除术存在穿孔率和环周切缘阳性率高的问题,预后较差。肛提肌外腹会阴联合切除术通过扩大切除带来的肿瘤学获益仍有争议,且该手术创伤大,并发症发生率较高。本文回顾两项手术发展历史,评价相关循证医学证据,并提出一种腹腔镜主导下的腹会阴联合切除术。该手术在腹腔镜直视下经盆腔途径个体化切除肛提肌,将其最大程度保留用于盆底重建;将手术汇合平面降至坐骨直肠窝脂肪,简化会阴部操作;并具备腹腔镜手术操作精细,利于盆部自主神经保护的传统优点,是一种值得在实践中进一步完善推广的新术式。

In the field of surgical treatment for low rectal cancer, the traditional abdominoperineal excision (APE) do not benefit much from the total mesorectal excision (TME) prinple, but is trapped by the so-called ?surgical waist? and associated oncological inferiorities. The safety of a more radical procedure, the extralevator abdominoperineal resection (ELAPR) is still under debate. Owing to the advancement of laparoscopic techniques, we developed a laparoscopy-cotrolled APE (LCAPE) procedure for stage I-III patients. During the procedure, a controlled incision of levators into the ischiorectal fat was performed transabdominally under direct vision; the meeting plane is therefore lowered and the perineal dissection simplified without changing body position. This laparoscopic guided technique has innate advantages in neurovascular preservation, and offers individualized transection of levator muscles, minimizes the risk of wound complications and prevents surgical waist to ensure oncological safety.

表1 APE和AR的肿瘤学效果对比表(%)
表2 最新APE与ELAPE手术短期与长期效果比较表(%)
表3 腹腔镜与开腹直肠癌远期疗效RCT研究比较表(I级证据)
[1]
Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908). CA: a cancer journal for clinicians, 1971, 21(6): 361-364.
[2]
Collins DC. End-results of the Milesʹ combined abdominoperineal resection versus the segmental anterior resection. A 25-year postoperative follow-up in 301 patients. American journal of proctology, 1963, 14: 258-261.
[3]
Fick TE, Baeten CG, von Meyenfeldt MF, et al. Recurrence and survival after abdominoperineal and low anterior resection for rectal cancer, without adjunctive therapy. European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 1990, 16(2): 105-108.
[4]
Groves RA, Harrison RCCarcinoma of the rectum and lower sigmoid colon:abdominoperineal or anterior resection? . Canadian journal of surgery Journal canadien de chirurgie, 1962, 5: 393-403.
[5]
Slanetz CA, Herter FP, Grinnell RS. Anterior resection versus abdominoperineal resection for cancer of the rectum and rectosigmoid. An analysis of 524 cases. American journal of surgery, 1972, 123(1): 110-117.
[6]
Vandertoll DJ, Beahrs OH. Carcinoma of rectum and low sigmoid; Evaluation of anterior resection of 1, 766 favorable lesions. Archives of surgery, 1965, 90: 793-798.
[7]
Heald RJ, Husband EM, Ryall RDThe mesorectum in rectal cancer surgery--the clue to pelvic recurrence? . The British journal of surgery, 1982, 69(10): 613-616.
[8]
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet, 1993, 341: 457-460.
[9]
Wibe A, Moller B, Norstein J, et al. A national strategic change in treatment policy for rectal cancer-implementation of total mesorectal excision as routine treatment in Norway. A national audit. Diseases of the colon and rectum, 2002, 45(7): 857-866.
[10]
Martling AL, Holm T, Rutqvist LE, et al. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet, 2000, 356(9224): 93-96.
[11]
Wibe A, Syse A, Andersen E, et al. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Diseases of the colon and rectum, 2004, 47(1): 48-58.
[12]
Holm T. Controversies in abdominoperineal excision. Surgical oncology clinics of North America, 2014, 23(1): 93-111.
[13]
Nagtegaal ID, van de Velde CJ, Marijnen CA, et al. Low rectal cancer:a call for a change of approach in abdominoperineal resection. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 2005, 23(36): 9257-9264.
[14]
Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Annals of surgery, 2005, 242(1): 74-82.
[15]
den Dulk M, Putter H, Collette L, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. European journal of cancer (Oxford, England: 1990), 2009, 45(7): 1175-1183.
[16]
Law WL, Chu KW. Abdominoperineal resection is associated with poor oncological outcome. The British journal of surgery, 2004, 91(11): 1493-1499.
[17]
Heald RJ, Smedh RK, Kald A, et al. Abdominoperineal excision of the rectum--an endangered operation. Norman Nigro Lectureship. Diseases of the colon and rectum, 1997, 40(7): 747-751.
[18]
Eriksen MT, Wibe A, Syse A, et al. Inadvertent perforation during rectal cancer resection in Norway. The British journal of surgery, 2004, 91(2): 210-216.
[19]
den Dulk M, Marijnen CA, Putter H, et al. Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Annals of surgery, 2007, 246(1): 83-90.
[20]
Holm T, Ljung A, Haggmark T, et al. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. The British journal of surgery, 2007, 94(2): 232-238.
[21]
West NP, Anderin C, Smith KJ, et al. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. The British journal of surgery, 2010, 97(4): 588-599.
[22]
Bebenek M. Abdominosacral amputation of the rectum for low rectal cancers: ten years of experience. Annals of surgical oncology, 2009, 16(8): 2211-2217.
[23]
Anderin C, Martling A, Hellborg H, et al. A population-based study on outcome in relation to the type of resection in low rectal cancer. Diseases of the colon and rectum, 2010, 53(5): 753-760.
[24]
Messenger DE, Cohen Z, Kirsch R, et al. Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection. Diseases of the colon and rectum, 2011, 54(7): 793-802.
[25]
Bulow S, Christensen IJ, Iversen LH, et al. Intra-operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer. Colorectal disease:the official journal of the Association of Coloproctology of Great Britain and Ireland, 2011, 13(11): 1256-1264.
[26]
Krishna A, Rickard MJ, Keshava A, et al. A comparison of published rates of resection margin involvement and intra-operative perforation between standard and ′cylindrical′ abdominoperineal excision for low rectal cancer. Colorectal disease:the official journal of the Association of Coloproctology of Great Britain and Ireland, 2013, 15(1): 57-65.
[27]
Ortiz H, Ciga MA, Armendariz P, et al. Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. The British journal of surgery, 2014, 101(7): 874-882.
[28]
Klein M, Fischer A, Rosenberg J, et al. Extralevatory abdominoperineal excision (ELAPE) does not result in reduced rate of tumor perforation or rate of positive circumferential resection margin: a nationwide database study. Annals of surgery, 2015, 261: 933-938.
[29]
Prytz M, Angenete E, Bock D, et al. Extralevator abdominoperineal excision for low rectal cancer-extensive surgery to be used with discretion based on 3-year local recurrence results: a registry-based, observational national cohort study. Annals of surgery, 2015.
[30]
Mathis KL, Larson DW, Dozois EJ, et al. Outcomes following surgery without radiotherapy for rectal cancer. The British journal of surgery, 2012, 99: 137-143.
[31]
Rosenberg J, Fischer A, Haglind E. Current controversies in colorectal surgery: the way to resolve uncertainty and move forward. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland, 2012, 14(3): 266-269.
[32]
Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. The New England journal of medicine, 2004, 350(20): 2050-2059.
[33]
Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 2007, 25(21): 3061-3068.
[34]
Lacy AM, Delgado S, Castells A, et al. The long-term results of a randomized clinical trial of laparoscopy-assisted versus open surgery for colon cancer. Annals of surgery, 2008, 248(1): 1-7.
[35]
Buunen M, Veldkamp R, Hop WC, et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. The Lancet Oncology, 2009, 10(1): 44-52.
[36]
Marecik SJ, Zawadzki M, Desouza AL, et al. Robotic cylindrical abdominoperineal resection with transabdominal levator transection. Diseases of the colon and rectum, 2011, 54(10): 1320-1325.
[37]
Chi P, Chen ZF, Lin HM, et al. Laparoscopic extralevator abdominoperineal resection for rectal carcinoma with transabdominal levator transection. Annals of surgical oncology, 2013, 20(5): 1560-1566.
[38]
Stelzner S, Holm T, Moran BJ, et al. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Diseases of the colon and rectum, 2011, 54(8): 947-957.
[39]
Acar HI, Kuzu MA. Perineal and pelvic anatomy of extralevator abdominoperineal excision for rectal cancer:cadaveric dissection. Diseases of the colon and rectum, 2011, 54(9): 1179-1183.
[40]
Lange MM, van de Velde CJ. Urinary and sexual dysfunction after rectal cancer treatment. Nature reviews Urology, 2011, 8(1): 51-57.
[1] 燕速, 霍博文. 腹腔镜食管胃结合部腺癌根治性切除术[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 13-13.
[2] 母德安, 李凯, 张志远, 张伟. 超微创器械辅助单孔腹腔镜下脾部分切除术[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 14-14.
[3] 李国新, 陈新华. 全腹腔镜下全胃切除术食管空肠吻合的临床研究进展[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 1-4.
[4] 李子禹, 卢信星, 李双喜, 陕飞. 食管胃结合部腺癌腹腔镜手术重建方式的选择[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 5-8.
[5] 李乐平, 张荣华, 商亮. 腹腔镜食管胃结合部腺癌根治淋巴结清扫策略[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 9-12.
[6] 陈方鹏, 杨大伟, 金从稳. 腹腔镜近端胃癌切除术联合改良食管胃吻合术重建His角对术后反流性食管炎的效果研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 15-18.
[7] 许杰, 李亚俊, 韩军伟. 两种入路下腹腔镜根治性全胃切除术治疗超重胃癌的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 19-22.
[8] 李刘庆, 陈小翔, 吕成余. 全腹腔镜与腹腔镜辅助远端胃癌根治术治疗进展期胃癌的近中期随访比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 23-26.
[9] 任佳, 马胜辉, 王馨, 石秀霞, 蔡淑云. 腹腔镜全胃切除、间置空肠代胃术的临床观察[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 31-34.
[10] 赵丽霞, 王春霞, 陈一锋, 胡东平, 张维胜, 王涛, 张洪来. 内脏型肥胖对腹腔镜直肠癌根治术后早期并发症的影响[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 35-39.
[11] 吴晖, 佴永军, 施雪松, 魏晓为. 两种解剖入路下行直肠癌侧方淋巴结清扫的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 40-43.
[12] 周世振, 朱兴亚, 袁庆港, 刘理想, 王凯, 缪骥, 丁超, 汪灏, 管文贤. 吲哚菁绿荧光成像技术在腹腔镜直肠癌侧方淋巴结清扫中的应用效果分析[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 44-47.
[13] 王庆亮, 党兮, 师凯, 刘波. 腹腔镜联合胆道子镜经胆囊管胆总管探查取石术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 313-313.
[14] 杨建辉, 段文斌, 马忠志, 卿宇豪. 腹腔镜下脾部分切除术[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 314-314.
[15] 叶劲松, 刘驳强, 柳胜君, 吴浩然. 腹腔镜肝Ⅶ+Ⅷ段背侧段切除[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 315-315.
阅读次数
全文


摘要


AI


AI小编
你好!我是《中华医学电子期刊资源库》AI小编,有什么可以帮您的吗?